Improving Quality ≠ Quality Improvement

In this new blog series, Dr Amar Shah – Consultant forensic psychiatrist & Chief Quality Officer at ELFT – will explore all things QI, sharing tips and tricks, demystifying QI and sharing stories to inspire everyone to improve the system in which they work. Enjoy!

Over the last few years we have seen a proliferation in the interest and use of quality improvement in health and healthcare. This represents a really promising shift in our mental models about how to solve some of our most complex quality issues. Alongside the increasing use of the word ‘improvement’ in our everyday language within healthcare, I’ve observed some difference in understanding of what exactly we mean by the term “quality improvement”.

So, what is quality improvement? And is it any different from what we’ve always done? Surely we’ve always been trying to improve quality?

In helping people try to work through these questions, I often start with the provocation that improving quality is not the same as quality improvement. This often evokes some puzzled expressions. A simple reversal in words, but two very different concepts.

For any product or service, there are many ways we can improve quality. In healthcare, we’ve used many different mechanisms and methods to improve quality for decades. One approach is planning or redesign, which involves deeply understanding the needs of the population/customer/service user, looking at the evidence and best practice across the industry in order to ascertain what structures and processes we need to put in place. This is something we might do once a year. Another way to improve quality is through assurance: occasionally checking that we are meeting a particular standard or threshold. A third way to improve quality is through quality control, which incorporates really good operational management, monitoring performance in real-time within the team, taking action when needed to bring the system back into control, and escalating rapidly when we can’t solve a problem. The fourth way to improve quality is through quality improvement: a systematic method to solve complex problems through testing and learning, involving those closest to the issue deeply in discovering new solutions.

So, quality improvement is a particular, and very specific, approach to complex problem solving that relies on testing and learning (and failing many times). Quality improvement empowers those closest to the improvement opportunity to discover a better way, and should deeply involve both staff, patients, service users and carers in understanding the issue, identifying new ideas and testing these out to see which work within the given context. As we are looking to learn whether a particular service or issue has improved, we also look at data quite differently, in order to see whether something has changed over time.

This leaves us with an exciting opportunity. The emergence of quality improvement can build on all our efforts to date, rather than replace them. The real questions are whether we are able to identify the right kind of challenges and opportunities for which quality improvement is perfectly suited, and whether we can create the appropriate conditions in which quality improvement can thrive…